Monday, November 23, 2009

Swine flu discrepancies

The Expat. I mean this as a serious discussion question, so I hope I get serious answers. In the K-blogs we frequently read what a waste of time and/or failure swine flu prevention measures are in South Korea.

If that is the case (or even if it isn't), why does the United States have a per capita death toll eight to ten times higher than in the ROK? Specifically, the most recent mortality numbers in South Korea are 82 (though that has probably gone up at least into the 90s or even triple digits), while the last widely released figure in the US was a couple weeks ago at 3900.

That's nearly fifty times the number of deaths, but the US is only six times larger than South Korea in population, so with those numbers, we're looking at an 8-to-1 ratio when we compare per capita rates.

South Korea's relative isolation could be a reason, but Hawaii is equally as isolated (almost everyone comes in and out through airports which are equipped to check for people carrying fruit in their bags), but the ratio still holds. Is South Korea under-reporting? Is the US over-reporting? Are the ROK regulations really working?

What explains the discrepancy? Discuss. (Incidentally, the catalyst for this question was a remark at Ask The Expat, but I've been mulling this as a discussion topic for some time.)

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11 comments:

  1. I think you answered your question exactly. Korea's relative isolation helps limit the number of cases. Yes, Hawaii may be an island thousands of miles from any mainland, but it's still a heavily trafficked place. More people are coming in and out of Hawaii than Korea, therefore limiting the number of people bringing in flu germs. Also, within Korea, there is also a bit of isolation. People generally aren't moving around. They stay in a tiny area going from work to school to home mostly within their small neighborhoods and communities.

    Also, extremes in under reporting of flu cases in Korea blurs the numbers. The United States keeps careful documentation of flu cases every year. An estimated 36,000 people a year die of flu related illness in the states. There is a centralized database for the US health department to keep track of this information and many illnesses are attributed to flu related as a best guess. Also, the tracking for US swine flu cases are nearly all estimates.

    In Korea, there is no centralized system to keep track. More than that, people don't see the doctor when they are ill or when they do, their symptoms are considered a bad cold. We have all seen our students miserably passed out at their desks because they are so ill. I'm willing to bet that more often than not, especially in this season, they have the flu and it's not being reported.

    Apart from those reasons, in my opinion, I think the US has a higher incidence of flu because of the over use of vaccines. The flu vaccine in the states is almost a requirement and I think this plays a huge factor in enabling mega viruses to mutate, grow, and spread quicker.

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  2. Proximity, proximity, proximity.

    Hawaii gets more domestic mainlanders than Koreans traveling to the US.

    Korea now has manadatory vaccinations as well as Japan.

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  3. If you check flucount.org, they cite some non-specific "reliable" sources that list South Korea as the second most infected country in the world. Is it possible that in Korea it is being treated differently, resulting in a lower death toll?

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  4. Kristen wrote:
    I think you answered your question exactly. Korea's relative isolation helps limit the number of cases.

    To some degree, I think that's true, but I don't think it explains all of it. I'm very thankful to JohnB for the link he provided (more on that later), which I can use to illustrate some points.

    First, I see now I could have posed the question differently: Why does Japan, with 2.5 times the population of South Korea, have slightly fewer than the total of South Korea's deaths? Certainly isolation can't be the whole answer, particularly since Japan has more connectivity to the US than South Korea does.

    If I were to pose my question is a thesis, it would be to ask whether relatively stricter identification, control, and/or quarantine policies have made a difference in infection and/or mortality. Japan seemed more on top of things as far as closing schools (they did so earlier on, afaik), and that might explain the lower infection and mortality, but then that would suggest something similar is at play with Korea vis-à-vis Hawaii and the Mainland US.

    Yes, Hawaii may be an island thousands of miles from any mainland, but it's still a heavily trafficked place. More people are coming in and out of Hawaii than Korea, therefore limiting the number of people bringing in flu germs.

    More people coming in and out relative to the size of the population, but not more people. Incheon International Airport has 30 million passengers per year and Honolulu International Airport has only 22 million. Most of both sets of numbers are coming from "off-island," so to speak.

    But this is something I want to emphasize as a difference, having flown into Honolulu twice and into Inchon twice during between the months of May and August: At Seoul there were efforts on the plane and in the terminal to determine who might be sick and where they were sitting, and then get ready to put them in isolation.

    By contrast, arriving in Honolulu it was business as usual, literally. The Hawaii Tourism Board still wanted my arrival card that asked what I was planning to do in the Aloha State and for how long, and there is an army of X-ray attendants checking just for wayward produce that ends up in people's bags as they leave, but nothing — absolutely nothing — to check if people arriving on our shores were bringing a pandemic.

    Also, within Korea, there is also a bit of isolation. People generally aren't moving around. They stay in a tiny area going from work to school to home mostly within their small neighborhoods and communities.

    I don't find that true at all. There is huge a mount of movement throughout Seoul alone, with millions riding the subway and millions more riding the bus system, both of which provide nodes of infection that wouldn't exist if they mulled around their neighborhoods. I'd certainly say people in Honolulu are less likely to come into contact with high numbers of people from outside their 'hood.

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  5. Kristen wrote:
    Also, extremes in under reporting of flu cases in Korea blurs the numbers. The United States keeps careful documentation of flu cases every year.

    Respectfully, I think you are wrong on this as well. The stats provided by JohnB indicate, if anything, that ROK authorities are reporting just about any case they suspect of being H1N1 as H1N1. By contrast, the US announced it had stopped doing lab tests to confirm for H1N1, suggesting it was inefficient use of resources, once it was clear there was a pandemic. Look at the difference between official infections and unofficial infections, which is almost double. I've seen that 44,555 figure for some time now; it's frozen.

    An estimated 36,000 people a year die of flu related illness in the states. There is a centralized database for the US health department to keep track of this information and many illnesses are attributed to flu related as a best guess. Also, the tracking for US swine flu cases are nearly all estimates.

    That appears to be the case, definitely. I'm not so sure it is in Korea, though.

    In Korea, there is no centralized system to keep track.

    That is not correct. There is a Korean CDC, and they have been on red alert since the first transmissions from overseas started occurring.

    More than that, people don't see the doctor when they are ill or when they do, their symptoms are considered a bad cold.

    Actually, South Koreans are documented as being overly concerned about symptomatic conditions. And since the H1N1 pandemic began rising, the South Korean medical establishment, from what I could gather, has been highly sensitized to the possibility of individual cases being H1N1.

    We have all seen our students miserably passed out at their desks because they are so ill.

    Not me. I'm not a teacher. :)

    But, yeah, in the workplace I've seen that happen and I really loathe that kind of behavior. But the point was driven home through the media and through corporations themselves from beginning in the the outbreak trajectory that this should not be done.

    And maybe that right there could be a difference between the US Mainland and Hawaii, where South Korean authorities and the public could read about it unfolding in the US and think how to react before it started coming to South Korean shores in large numbers. Of course, the same is true for Hawaii, where health authorities were less likely to react in any urgent way.

    Even after May, have your students been coming to school sick from might be a cold or flu?

    Apart from those reasons, in my opinion, I think the US has a higher incidence of flu because of the over use of vaccines. The flu vaccine in the states is almost a requirement and I think this plays a huge factor in enabling mega viruses to mutate, grow, and spread quicker.

    Explain the mechanism of how that would work. By vaccinating someone, they will not be infected and will not transmit it, which curtails the ability of the virus to mutate.

    It's quite different from, say, taking antibiotics which create super bugs.

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  6. The Expat wrote:
    Proximity, proximity, proximity.

    I think you mean connectivity, connectivity, connectivity. Honolulu is closer to Tokyo than it is to Houston, close to what was the point of entry for H1N1 into the US, so it's not geographic proximity at all.

    Hawaii gets more domestic mainlanders than Koreans traveling to the US.

    This is true, of course, and I would certainly believe that is a major component of the difference, but does it explain all of the eightfold difference? Hawaii and South Korea both started experiencing infections from the US Mainland at about the same time.

    Maybe Hawaii had more feeder cases coming in, which would cause the numbers to go up, but the utter lack of gatekeeping control and thus quarantining seems to be a part of it as well.

    Going from anywhere in the US to Hawaii requires travel through narrow corridors and portals, where gatekeepers can be placed, as was done in Korea, but none of this was done in Hawaii.

    Korea now has manadatory vaccinations as well as Japan.

    You mean for non-H1N1 flu as well, or just H1N1?

    Anyway, my apologies for accidentally hijacking the comments at that post on your website. That's why I tried to pull the conversation over here.

    My intent is not to justify the strict attempts at identifying, controlling, and quarantining, some of which may have been overboard and unnecessary.

    But much of the K-blog commentariat seems to be of the consensus that it was all for naught and I'm not convinced that was the case. Trying to find the cases early on during the outbreak may have curbed the early spread. Canceling events that would create new nodes of infection may also have saved lives. It may very well have come down to a question of how many lives is my Chusok vacation worth, or how many lives is that kimchi festival worth?

    The K-blogs were also concentrating heavily on perceptions of discrimination in the early stages, to the point that many were ignoring the fact that Korean-language sources were reporting the Koreans who were infected just as heavily as the foreigners who were infected. But there was a time initially, for several weeks running, where NSETs were a majority of all known cases, and between NSETs, other foreign visitors or residents, and Koreans coming from abroad, all cases were of people infected outside the country.

    But it does seem as if much of the K-blog commentariat was reacting (and still reacting) as if the whole effort to contain H1N1 as much as possible is a sham based on that initial impression that NSETs were being singled out and discriminated against.

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  7. JohnB wrote:
    If you check flucount.org,

    First off, let me thank you again for providing this link. I'm surprised I didn't find it before. I'd been trying to find each of these data points individually here and there, so it's nice to have an updated and accurate list (accurate meaning it jives with stuff I found from direct sources).

    they cite some non-specific "reliable" sources that list South Korea as the second most infected country in the world. Is it possible that in Korea it is being treated differently, resulting in a lower death toll?

    I think it's the opposite. As I mentioned to Kristen, I think almost everything that could possibly be H1N1 is being assumed to be H1N1. By contrast, in the US they have stopped verifying H1N1 infection for data gathering purposes.

    So while there may be a discrepancy in the reporting of infections which could work against, say, South Korea or Germany, I think the real comparison comes in actual death rates. Knowing how things work in public health in South Korea, probably any conceivable H1N1 death is being investigated as such, so I don't think the number is under-reported.

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  8. "K-blog commentariat was reacting (and still reacting) as if the whole effort to contain H1N1 as much as possible is a sham based on that initial impression that NSETs were being singled out and discriminated against.

    You know the game, kushibo. Play the part of the persecuted and rile the troops.

    I'll be in the US and Mexico for the next six weeks and am looking forward to seeing what -if any- precautions are being taken.

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  9. I'll give further thought and reflection to the other questions posed, but for now I can answer this one:
    Even after May, have your students been coming to school sick from might be a cold or flu?

    Yes! My student have definitely been coming to school when they are ill. I had one student that passed out at his desk and the other students reported that he'd had a fever for a few days. When I did a simple forehead check, the boy was burning up! But the reason he was not allowed to stay home was because there were exams that week. This is elementary school!

    My school 'closed' recently because of a swine flu outbreak. The number of cases was quite high. Still, the school was not actually closed. The newspapers reported it closed but both students and teachers were still required to come to school. My students wear uniforms, but for those days, they were told not to wear their uniforms so that the school could resume regular operations without much notice. Similar scenarios were mentioned by other foreign teachers at my school.


    I'll do my best to respond to the other points as soon as I can tomorrow. :)

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  10. Kristen wrote:
    Yes! My student have definitely been coming to school when they are ill. I had one student that passed out at his desk and the other students reported that he'd had a fever for a few days. When I did a simple forehead check, the boy was burning up! But the reason he was not allowed to stay home was because there were exams that week. This is elementary school!

    I'm hoping that the swine flu pandemic will lead to a shift in this kind of thing: people feeling that they are forced to go to work or school even when they are sick. Unfortunately, the schools in Korea generally don't have a "make-up exam" system in place (or if they do, they don't like to use it). Of course, in the US, it's an abused privilege, but that's another story.

    What month did this occur? If it were "early on" in the whole H1N1 situation, I could understand it but not excuse it. And about that...

    My school 'closed' recently because of a swine flu outbreak. The number of cases was quite high. Still, the school was not actually closed. The newspapers reported it closed but both students and teachers were still required to come to school. My students wear uniforms, but for those days, they were told not to wear their uniforms so that the school could resume regular operations without much notice. Similar scenarios were mentioned by other foreign teachers at my school.

    Where is your school? This may even be criminal conduct. If this were happening at a school I was working at or someone in my family was attending, I would have (anonymously, maybe even have someone else calling for me) contacted the local school board, the local ministry of education, and possibly the press.

    This angers me, really.

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  11. Joseph Mercola's latest newsletter at his website has a relevant interview with a CBS reporter who talks about her investigation into swine flu statistics. VERY interesting. Mercola is a bit of a scaremonger who uses stories of carcinogens and other health dangers lurking in our world to push his overpriced products, but often he is the first to make me aware of a genuine concern.

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